Global Assessment of Functioning Following Assertive Community Treatment in Edmonton, Alberta: A Longitudinal Study

Philip Tibbo, MD, FRCPC1, Ken Joffe, MSc, MD2, Pierre Chue, MRCPsych3, Andrei Metelitsa4, Evelyn Wright, RN, BscN, MS5

Objective: To examine longitudinally the effects of Assertive Community Treatment (ACT) on Global Assessment of Functioning (GAF) scores in Edmonton, Alberta.
Methods: We acquired GAF scores for all clients at initial registration in the ACT program and at subsequent 18- and 36-month time points while in ACT. We analyzed both the entire ACT cohort and separate diagnostic groups.
Results: We obtained baseline and follow-up GAF scores for 411 clients, of whom the largest diagnostic group suffered from schizophrenia (n = 189), followed by bipolar disorder (n = 98). Collapsed across all groups, GAF scores significantly improved at both 18 (P < 0.0001) and 36 months (P < 0.0001). By group, at 18-month follow-up, significant improvements were seen in patients with delusional disorder (P < 0.05), dysthymia (P < 0.05), schizoaffective disorder (P < 0.05), and schizophrenia (P < 0.001). This was also seen at 36-month follow-up, with the addition of significant improvements in those with bipolar disorder (P < 0.05). Those patients with major affective disorder or psychosis not otherwise specified (NOS) did not show significant improvements over time. Regardless of diagnosis, those clients with baseline GAF scores of £ 40 significantly improved at both 18-month (P< 0.0001) and 36-month (P< 0.0001) follow-up, while those with baseline GAF scores above 40 did not show significant improvement.
Conclusions: GAF scores improvedat 18- and 36-month follow-up from enrolment in an ACT program. Groups with different diagnoses and levels of functioning at time of enrolment may not benefit to the same degree.

(Can J Psychiatry 2001;46:131-137)

Key Words: assertive community treatment, global assessment of functioning, chronic mentally ill

Assertive community treatment (ACT) is a model of psychiatric community treatment for individuals with chronic mental illness. This model is intensive, yet comprehensive and flexible where it is accepted that clients have a right to live in as normal an environment as possible. This normal environment is, however, attained with intensive supports and services tailored to clients’ needs. The aims of ACT are to prevent unnecessary and lengthy hospital stays and to improve the length and quality of the client’s tenure in the community; it endeavours to deal with problems arising in the community that may otherwise lead to a hospital admission. Therapists assist clients to connect with their community and to make positive use of resources available to meet their housing, employment, health, and leisure needs.

Manuscript received November 1999, revised, and accepted June 2000.
1Clinical Fellow, Alberta Heritage Foundation for Medical Research, Department of Psychiatry, University of Alberta, Edmonton, Alberta.
2Resident in Psychiatry, University of Alberta, Edmonton, Alberta.
3Assistant Clinical Professor, Department of Psychiatry, University of Alberta; Clinical Coordinating Psychiatrist, Community Living Program, Edmonton, Alberta.
4Undergraduate Student, University of Alberta, Edmonton, Alberta.
5Program Manager, Community Living Program, Edmonton, Alberta.
Address for correspondence: Dr P Tibbo, Department of Psychiatry, University of Alberta Hospital, 8440 112 Street, Edmonton, AB  T6G 2B7
E-mail:ptibbo@pop.srv.ualberta.ca

This model (formally known as “Training in Community Living” or “Program of Assertive Community Treatment”) was originally developed in Madison, Wisconson, in the 1970s (1,2) and has since been adapted for other urban and rural North American settings (3–5).  As part of the Community Living Program (CliP), ACT was initiated in Edmonton, Alberta, on April 1, 1993. It has grown to a program employing 19 psychiatrists, 24.8 full-time equivalent (FTE) community nurses, and 2.5 FTE community support workers. The main program elements of Edmonton’s ACT model are based on Stein and Test’s original model (1,2), which includes low staff–client ratios, assertive outreach, 24-hour availability, active assertive advocacy and monitoring, continuity between community and hospital care, and flexible, individualized services.

Although there is substantial research on the effects of ACT on several outcome variables (for example, hospitalization rates and emergency-room visits) in the US (reviewed in 6,7), there is little research on this model in Canada, despite its implementation in several Canadian settings (8–11). We recently reported on hospital outcome measures for a cohort of

Next